GW1-2023-02210_Well Construction - GW1_20230307

I+' .Print Form .
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
---,S.axii TO4613 "14.'WATERZONES__.z ..-r,. d
Well Contractor ame FROM TO DESCRIPTION
� o ft ft 1
ft. ft.
NC Well Contractor Certification Number
15zOUTER;CASING(9iIiiilti casedlwella);OR•LINER'(irip"livable):,:; .
Morgan Well &Pump, INC FROM TO { DIAMETER 1 THICKNESS MATERIAL
1 ft 6 �
4 it. 61/8 in* sdr21 pvc
Company Name
��l r _f 16i INNIIYCASING OR TCIBING`(gblitheimarclosedl6op),.i ..:r�::1_ __.„.
(2.Well Construction Permit#: If U6', FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
r 17:`SCREEN.>_.'- ^ f.
Water Supply Well: = t _.. . M1
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural f Municipal/Public ft. ft. in.
-1 Geothermal(Heating/Cooling Supply) l'AiResidential Water Supply(single) ft It in.
' 7 Industrial/Commercial •Residential Water Supply(shared)
t:.VGROUT..,.._ .. . .... , '"'.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite poured
Monitoring I Recovery ft. ft.
Injection Well:
Aquifer Recharge
ft. ft.
= Groundwater Remediation
^19i.SAND/GRAVELPACK(ifapph able)' :.
Aquifer Storage and Recovery ©�'ISahnity Barrier FROM TO MATERIAL l y EMPLACEMENT METHOD
Aquifer Test J Stormwater Drainage it ft.
Experimental Technology DISubsidence Control it ft.
Geothermal(Closed Loop) Tracer 20:DRILLIxGT.OG(attach'sdditiorialsheets fnecessary) '.
Geothermal(Heating/Cooling Return) in Other(explain under#21 Remarks). FROM TO D CR^IPTION(color,hardness"sotl/mck type,grain size,etc.)
jb ft 41 0 It. 1=C/®(,tour, a is-,�+
o- _ K� W� t
4.Date Well(s)Completed: I 1� 23 Well iD# (4 0 ft S ft. .j-?.n di/s• .
5a.Well
i' /Locatiio�n:) .,r� r 5 ft (C ft. /Sam aLI n��
V1r) WWQt fr - /OOt. 4• 7ft axse1c C�_•
Facility/Own r Name Facility ID#(if applicable) /37f t Vj ft. -6`t'PJ 1 �j Q
} l a (..each 28 . ft vv ft. -- s
Physical Address,City,and Zip ft. ft � ( ,.,
p:2t,REMARKS .?` q / /
Co ��� Parcel Identification No.(PII� �`I A R t} '1 L�i L 3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
field,one lt/long is sufficient) 22.Certific "on' v',•��;Cl .'"`'
59
V , 733 N go. 6zQ�.1�' S w L G-ZO
6.Is(are)the well(s)KIPermanent or IiTemporary Signs of edified Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EllNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this.record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. .
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /V‘ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@'200'and 2@100') construction to the following:
vl 10.Static water level below top of casing: 2 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYY�WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 'GAS Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
e./J.�/ the address(es) above, also submit one Copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: Li% completion of well construction to the county health department of the county
or where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016